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THIRD PARTY REIMBURSEMENTFY12 BILLING READINESSQUESTION/ANSWER DOCUMENT # 1August 1, 2011No.1Question/ResponseQuestion:At this time we have one issue requiring clarification regarding insurance/Medicaid coverage. Do we bill the insurancecompany for SST prior to billing Medicaid?Response:Yes, you will need to bill SST to the child's private insurance first if the child has both Medicaid and private insurance. Weunderstand that some companies have paid for these services. See section 6.12.2 of the Texas Medicaid ProviderProcedures Manual, Volume 1 for further information.2Question:How I can get a "2011 Texas Medicaid Provider Procedures Manual, Children's Services Handbook"?Response:Medicaid providers are mailed a CD copy of the Provider Procedures Manual. Providers may download the manual directlyfrom the TMHP website. (TMHP.com) However, if they do not have internet, they can call the contact center to requestadditional CD's. The telephone number for the Contact Center is 1-800-925-9126.TMHP also offers provider training ontopics such as "Medicaid Basics", R& S Reports. The training schedule may be accessed on the TMHP website athttp://www.tmhp.com/Pages/Education/Ed Home.aspx3Question:In the „Things to Remember‟ section at the end, there is a statement about back billing services for kids with retroactiveMedicaid. Do we back bill the TCM services provided prior to eligibility or prior to an IFSP? The bulletin information fromTMHP says „providers may submit claims for TCM services that are included in the client‟s IFSP.‟ Just need a clarificationon that. And what if a child is eligible but does not enroll for some reason, are those TCM services billable?Response:You should not bill TCM services if they were provided prior to ECI eligibility. You can bill for TCM services provided to achild after ECI eligibility and prior to the IFSP.1
THIRD PARTY REIMBURSEMENTFY12 BILLING READINESSQUESTION/ANSWER DOCUMENT # 1August 1, 2011No.Question/Response4Question:Can you clarify the procedure codes to be used for on-going therapy for non-managed care enrolled clients after 10/1/11.We understand that the claims will be submitted under the group provider number (currently used for TCM). Do we use thesame procedure code as SST (T1027) with the appropriate therapy modifier or do we use the actual therapy procedurescodes (ex: 97110, 97112, 97116, 92507) with the appropriate therapy modifier?Response:You will use the actual therapy procedure codes and appropriate therapy modifier for all children (managed care and nonmanaged care). Then, in March, 2012, you will bill the therapy procedure codes to managed care for the children enrolledin managed care. The codes payable for PT, OT and ST ongoing services are listed in the September/October TexasMedicaid Bulletin, # 237, which was published on the TMHP website on July 20, 2011. The list of procedure codes is alsoin the Provider Notification of June 17, 2011, "Claims for Early Childhood Intervention Services to be Submitted to TMHPEffective October 1, 2011.5Question:As we will be receiving different revenue amounts from TMHP, will we be able to easily identify what services we are beingpaid for on the R&S statements?Response:The R&S reports indicate the claim number, client Medicaid number, service delivery date, service billed (by billing code),modifiers (if applicable), number of units billed, date submitted, amount billed, amount paid, date paid. If the claim does notpay (in part or whole) the R&S will include an explanation of benefit (EOB) code that explains why it didn't pay the fullamount. Things like: billed amount exceeds rate, therapy service on the same day as an evaluation by same provider,unauthorized provider, etc. The following link sends you to the R&S Reports training which you can do from your computer.We encourage you to access this training at: http://www.tmhp.com/CBT Library/Remittance%20and%20Status/index.htm2
THIRD PARTY REIMBURSEMENTFY12 BILLING READINESSQUESTION/ANSWER DOCUMENT # 1August 1, 2011No.Question/Response6Question:If the IFSP is the authorization for services, and the grid says that a service will be provided 4 x a month, if the providerthends up doing a 5 visit because the usual day of the service occurs 5 times in a particular month, will that extra visit bedenied because it technically is not authorized? Our usual practice is to do a 5th visit on those months to either make up amissed visit which is bound to occur at some point or to look ahead to a holiday or vacation when a visit might be missed.Would it be better to go ahead an enter services as 1 x week or 24 x for a six month period?Response:The IFSP must document the frequency and intensity of the services. Any claims paid by TMHP may be subject torecoupment.7Question:Is the rate issued for SST the same as the rate for ongoing therapy services that we will bill to TMHP?Response:No. The rates for SST are 31.63 for each 15 minute increment of individual services and 7.91 per 15 minute incrementof group services. The ongoing therapy services will be reimbursed at the same rate as the comprehensive care program.See the HHSC Rate Analysis website at: html8Question:Just wanting to be sure that after March 1, 2012, we will still bill ongoing therapy services to TMHP. I understand that wewill continue to bill SST to TMHP but am still not sure about ongoing therapy. I understand that we will bill evaluations,nutrition, counseling, and audiology to the MCOs.Response:You will NOT still bill ongoing therapy services to TMHP after March 1, 2012 for children enrolled in managed care. OnMarch 1, 2012, all ongoing therapy services will be billed to the MCOs. Only the SST and TCM will continue to be billed toTMHP after March 1, 2012. All other services will be billed to the MCOs as you do now--evaluations, nutrition, counselingand audiology.3
THIRD PARTY REIMBURSEMENTFY12 BILLING READINESSQUESTION/ANSWER DOCUMENT # 1August 1, 2011No.9Question/ResponseQuestion: Are we going to bill SST and TCM to commercial insurances?Response:You should attempt to bill SST and TCM to commercial insurance companies. We understand that some companies havepaid for these services. If you receive a denial because this is not a covered benefit and the child is not on CHIP orMedicaid, then you can document your attempts and you would not need to continue to bill each service on a regular basis.However, you should check the benefit coverage periodically, for example, once per quarter.10Question:If we do not require a RX to bill SST to Medicaid, do we not require a DX to go out on the claims? if we do need a DX,where do you suggest we obtain that from as now we get them from the RX's?Response:The CMS-1500 claim form requires a diagnosis on the claim. Even when a RX is not required, the review of medicalrecords is an important component of planning medically necessary services for children, and information in the medicalrecord may provide a diagnosis. See proposed TAC 108.1005 which contains ECI requirements for review of medicalrecords prior to the development of an IFSP. A diagnosis may be also determined by a Licensed Professional of theHealing Arts (LPHA) on the child's team (when acting within the scope of their licensure).11Question:What claim forms (HICFA CMS-1500 or UB-04) do we use to bill SST, TCM and therapy services to TMHP?Response: The claim forms used for billing SST, TCM and therapy services to TMHP are the CMS-1500 claim forms. SeeSection 6.5 of the TMPPM, Volume 1, General Information, for additional information regarding paper and electronic claims.12Question:What claim forms do we use to bill the evals to TMHP?Response:The claim forms used for billing evaluations to TMHP are the CMS-1500 claim forms. See Section 6.5 of the TMPPM,Volume 1, General Information, for additional information on paper and electronic claims.4
THIRD PARTY REIMBURSEMENTFY12 BILLING READINESSQUESTION/ANSWER DOCUMENT # 1August 1, 2011No.13Question/ResponseQuestion:Can we bill re-evals to Medicaid? if so how? what forms do we use? what reimbursement rate can we expect from them?Response:Yes, you can bill Medicaid for re-evaluations. These are billed in the same manner as the evaluations. The claim forms arethe same and the reimbursement to expect is the same. The re-evaluations can not be billed more frequently than every 30days. See Section 6.5 of the Texas Medicaid Provider Procedures Manual, Volume 1, General Information. Also seeSection 2.10, Therapy Services (CCP) of the Texas Medicaid Provider Procedures Manual, Volume 2, Children's ServicesHandbook.14Question:Is there going to be a limit of TCM Billing that can be done in a month?Response:There is no limit on the number of TCM billings that can occur in a month—it is based on the needs of the child. However,the documentation in the record must support the need for the service and billing of the service. ECI state office will bemonitoring the amount of TCM billing.15Question:You specifically said that TCM and SST will not require authorizations with Medicaid - what about OT, ST, and PT?Response:The IFSP is acting as the authorization so there is not a separate requirement to get an authorization from TMHP for OT,PT or ST when you start to bill these services to TMHP in October. The therapists must, however, comply with theirpractice acts, some of which require a prescription prior to performing services.16Question:If an ECI consumer has private insurance and Medicaid, do we have to bill the private insurance first for OT, PT and ST?Response:You will need to bill private insurance first for OT, PT and ST if the child has both private insurance and Medicaid.5
THIRD PARTY REIMBURSEMENTFY12 BILLING READINESSQUESTION/ANSWER DOCUMENT # 1August 1, 2011No.Question/Response17Question:We are in the process of activating some new codes to use for PT,OT, SLP consultation. We don't find any CPT codes thatseem to fit. We are concerned that we won't be able to bill for these. What did ya'll have in mind in regards to billing forconsultations?Response:This will be covered in the presentation/webinar of August 3rd, 2011.18Question:Is there a special process for getting a TCM "expanded provider enrollment?"Response: No. As long as you have a TCM ECI provider enrollment that you use to bill your TCM services, you will notneed to do anything further regarding provider enrollment. However, you will be responsible for keeping the therapist'slicenses current as well as the EISs certifications current.19Question:Why do you bill the MCO for the PT/OT/ST evaluations but bill the services to TMHP?Response:The reason is that the PT/OT/ST evaluations have always been covered by CCP but the ongoing therapy services werecarved out of managed care. The MCO’s re procurement requires the MCOs to cover the ongoing therapy services forPT/OT/ST; however they are not included in the current MCOs contracts.20Question:Is there any way that we can bill for behavior intervention?Response:Medicaid doesn’t pay for behavioral intervention services. There may be insurance companies that will pay, so we wouldencourage you to bill any services to private insurance companies that your therapists perform, provided the professionaldetermines that there is a procedure code that is applicable and the service was provided according to the description ofthe code.6
THIRD PARTY REIMBURSEMENTFY12 BILLING READINESSQUESTION/ANSWER DOCUMENT # 1August 1, 2011No.21Question/ResponseQuestion:If providing SST to a set of twins, is this considered two individual or a group?Response:Each twin receives an individual service. Example, if each twin has 45 minutes of the same service planned, the providerwould remain in the home for 1.5 hours, and the time is split between the two children.22Question:Can a case manager bill TCM at the same time a service is being delivered (i.e. PT)?Response:It is not prohibited; however, the specific services being delivered should be delivered in a manner that allows the therapyor SST service to occur without distraction and each specific service would need to be documented. For example, It mightbe appropriate for the Service Coordinator to facilitate communication with the parent but it would not be appropriate for theService Coordinator to discuss advocacy with the parent while the other service provider is delivering a therapy or SSTservice.23Question:Is there a definition for SST so that we can use it for billing purposes across the state?Response:The definition for SST is in the proposed rule, 40 TAC Part 2, Chapter 108, Subchapter E. Specialized Skills Training. Itstates:"Specialized skills training (developmental services) are rehabilitative services to promote age-appropriate development byproviding skills training to correct deficits and teach compensatory skills for deficits that directly result from medical,developmental or other health-related conditions."7
THIRD PARTY REIMBURSEMENTFY12 BILLING READINESSQUESTION/ANSWER DOCUMENT # 1August 1, 2011No.24Question/ResponseQuestion:What is meant by "ongoing' therapy services in terms of frequency, specifically 1 x a month therapy-does it meet thedefinition of ongoing?Response:We assume that your question is in reference to planning LPHA services when SST is planned in the IFSP. At the time ofthe IFSP, the LPHA must determine whether their service is planned as "re-assessment" or "therapy" according to theanticipated activities for the service visits.So, for example:1. A therapist may anticipate that a service that is needed one time per month will meet the description of therapy becauseshe is going to be discussing daily routines with the family, suggesting and demonstrating activities and strategies, helpingthe parent make adjustments to their routines, etc. While there is a component of ongoing assessment to this type of visit,this would be considered “ongoing service”.2. Or, the same therapist may anticipate that a monthly service to another family is going to consist of primarily assessmentactivities like reviewing progress, identifying new needs, and then providing information to other team members. This wouldbe considered re-assessment.Note: TKIDS is being changed to allow "re-assessment" as a planned service. "Consultation will no longer be anavailable choice.25Question:Does the ECI state office have a process chart for what we are doing now & the upcoming changes for a quick reference?Response:If you are talking about where to bill services, there are some aids that are being developed that will be released inconjunction with the August 3rd webinar.8
THIRD PARTY REIMBURSEMENTFY12 BILLING READINESSQUESTION/ANSWER DOCUMENT # 1August 1, 2011No.26Question/ResponseQuestion:How does SST consultation fit into these billing changes?Response:This will be covered in the presentation/webinar of August 3rd, 2011.Note: TKIDS is being changed to allow "re-assessment" as a planned service. "Consultation will no longer be anavailable choice.27Question:As I read the bulletin NO. 237 it states that providers may submit all physical therapy, occupational therapy and speechtherapy services directly to TMHP billed with the TCM provider number. However it does state that providers will continue tosubmit claims for PT, OT and ST evaluation and re-evaluation to the CCP and these claims must include the individual CCPprovider. Is this correct for MCO as well bill the evals and re-evals to the MCO with the individual provider number? Pleaseclarify.Response:Yes, this is also true for MCOs—you will bill the evaluations and re-evaluations to the MCO with the individual providernumber, unless the MCO allows a group enrollment for the ECI Contractor.28Question:Does the IFSP have to say “SST” or can it say “DS” for the services that are already on the IFSP GRID?Response:The ECI Program rules use the term Specialized Skills Training with Developmental Services in parenthesis so we do notthink you will need to go back and update the IFSPs with the new term—just be sure to use it for any new IFSPs and alldocumentation effective September 1, 2011.9
THIRD PARTY REIMBURSEMENTFY12 BILLING READINESSQUESTION/ANSWER DOCUMENT # 1August 1, 2011No.29Question/ResponseQuestion:From the Fall Director‟s meeting, I understood that EIS staff were not allowed to participate in group services. Since SSThas a group rate, has that changed?Response:When you begin billing SST services to TMHP in October, you will be able to provide SST in a group setting according toproposed TAC 108.1107. The rates for SST are not effective until October 1, 2011.30Question:Can I go back and bill an initial evaluation for a child who was not eligible for Medicaid when the ECI evaluation was donebut who was later determined to be retroactively eligible for Medicaid and the Medicaid period includes the time when theinitial evaluation was performed?Response:Yes, you can go back and bill for the evaluation in the case you describe. There is no prerequisite of ECI eligibility prior tothe delivery of an evaluation.31Question:It shows that we are to bill code 92507 for speech therapy in 15 minute increments. However, in the cpt code book, thiscode shows to be a per visit code. I am wondering how I am going to be able to bill one way to Medicaid and bill differentlyto private insurance.Response:According to HHSC, procedure code 92507 is billed in 15 minute increments so you will need to bill it that way when billingTMHP.32Question:If a ECI consumer has private insurance and Medicaid, do we have to bill the private insurance first for OT, PT and ST?Response:Yes, you will need to bill a child's private insurance prior to billing Medicaid.10
THIRD PARTY REIMBURSEMENTFY12 BILLING READINESSQUESTION/ANSWER DOCUMENT # 1August 1, 2011No.Question/Response33Question:We are in the process of activating some new codes to use for PT,OT, SLP consultation. We don't find any CPT codes thatseem to fit. We are concerned that we won't be able to bill for these. What did ya'll have in mind in regards to billing forconsultations?Response:This will be covered in the presentation/webinar of August 3rd, 2011.34Question:When we set-up the new billing for Medicaid SST and CM - I understand that I will need to bill TMHP under my existingTCM Texas Provider Identifier number.In the presentation I thought I heard someone mention that if the consumer was Private Insurance and Medicaid that Iwould need to bill these services to Private Insurance prior to billing TMHP. I am not aware of any insurance company thatwill pay for these services under the published billing codes. So I was wanting clarification.I know most insurance companies will pay for PT, OT, and ST – so I will need to bill the private insurance (primary) beforebilling TMHPResponse:Yes, you will need to bill SST and TCM to private insurance prior to billing the services to Medicaid if the child has bothprivate insurance and Medicaid. See Section 6.12.2 Other Insurance Credits in the TMPPM, volume 1.35Question:Also – normally under the TCM TPI number, TMHP does not screen for private insurance, in the same manner they do forthe individual CCP provider billing- is this going to be a new TMHP edit that might delay reimbursement for the SST and CMservices?Response:Based on the most current information, the TMHP edit for PT, OT and ST will not be applied for SST and TCM.11
THIRD PARTY REIMBURSEMENTFY12 BILLING READINESSQUESTION/ANSWER DOCUMENT # 1August 1, 2011No.Question/Response36Question:In the presentation of July 27th, (Last Slide on Page 4) for those children enrolled in Medicaid Managed Care – I wanted tobe sure that everyone was aware that the psychological and counseling services are billed to the BHO and not the HMO,and these services may require a 2nd contract if the HMO has sub-contracted their Behavioral Health services to anothercompany. For example we have a contract with Community Health Choice and they pay for the traditional ECI services;however, the psychological and counseling services are paid by APS. Everyone needs to be aware in order to be proactiveand making sure they secure both contracts in order to maximize revenue.Response:This is a good point. In cases where the HMO has sub-contracted their Behavioral Health services, you need to determine ifa contract with the behavioral health organization is needed to bill any psychological and counseling services.37Question:Please confirm my understanding. If a service is provided for 68 minutes in time, all at once, then the billable time is 5 units.But, if 68 minutes of service is provided during the day in different events, then each service event has to meet the 15minute definition of at least 8 minutes long in order to be a billable unit.For example:-On 10/5/11 a service is provided to the parent in the morning for 61 minutes – this equals 4 units-On 10/5/11, a service is provided to the parent and with the school district rep in the afternoon for 7 minutes – this wouldnot equal a billable unitSo, in this case 68 minutes of service was provided but equals 4 units of billable services, not 5 units. Is this correct?Response:Yes, that is correct.12
THIRD PARTY REIMBURSEMENTFY12 BILLING READINESSQUESTION/ANSWER DOCUMENT # 1August 1, 2011No.Question/Response38Question:Just would like clarification on when activities are allowed to be billed to TCM. If a child is determined eligible for ECIservices, are case management services billable at that time, or are they only allowed once an IFSP and enrollment into theECI program is completed. If a child is eligible for services but does not enroll for some reason such as family decliningservices, are the billable activities that have occurred once eligibility is determined not allowed as TCM?Response:Billable TCM activities that have occurred once ECI eligibility is determined are allowed as TCM. Once a child isdetermined eligible for ECI, case management services are billable whether the child enrolls or not.39Question:The presentation stated that after October 1, we should bill ongoing PT, OT, ST services to TMHP when a child is enrolledin a managed care program using the appropriate procedure code with modifier. Does TMHP have edits in to prevent thisfrom rejecting, such as bill HMO?Response:Yes.13
Medicaid providers are mailed a CD copy of the Provider Procedures Manual. Providers may download the manual directly from the TMHP website. (TMHP.com) However, if they do not have internet, they can call the contact center to request additional CD's. The telephone number for the Contact Center is 1-800-925-9126. TMHP also offers provider .
